The following article appeared a few days ago.
Standards set for the structure of medical records
23 Oct 2008
Profession-wide standards for medical records in hospitals have been agreed for the first time.
The standards, developed by the Royal College of Physicians and NHS Connecting for Health, and backed by the Academy of Medical Royal Colleges, set out the structure of the clinical content doctors should record on admission, at handover, at out of hours handover and at discharge.
A spokesperson for CfH said it is working closely with suppliers to ensure the standards are built into their systems.
She added: "Implementation of the new record keeping standards is being managed according to requirements of local programmes. The records will first be incorporated into paper pro-formas, before being introduced into electronic records.
"The new standards are also being incorporated into the design of Cerner and Lorenzo. We are currently working with suppliers to draw up plans for implementation of the standards in acute trusts across the country."
Professor John Williams, director of the RCP Health Informatics Unit, also told E-Health Insider that incorporating the standards into electronic records would depend on the work CfH does with suppliers. But he expects the standards to be in use in every hospital in paper format over the next year.
“There isn’t a specific timescale for this to happen, and we haven’t been didactic, but I would like to see the structured proformas in use over the next year. We hope that they will be part of the training of junior doctors as they join; so the first milestone will be the next intake of house officers,” he said.
CfH and the RCP say the standards will improve safety by standardising the information held on patients during their hospital stay, reducing the likelihood of mistakes and of information being missing at admission, handover and discharge.
They should also mean that clinical information in electronic records should only need to be recorded once, improving efficiency and saving time. And they should simplify the implementation of new clinical information systems, as they can all be built to the same structure standards.
Much more here:
http://www.e-health-insider.com/news/4262/standards_set_for_the_structure_of_medical_records
Also from E-Health Insider there is some commentary by two experts on what the standards mean.
Getting records up to standard
22 Oct 2008
In the latest column from NHS Connecting for Health, chief clinical officer Professor Michael Thick is joined by Professor Iain Carpenter, associate director for records standards in the Health Informatics Unit at the Royal College of Physicians. They jointly talk about the standards the two organisations have just released for patient records.
Standardising the format of patient records is key to improving patient safety. The recent Health Informatics Review highlighted the importance of improving information standards across the NHS, and the need for clinicians to have the right patient information, at the right time, to deliver better, safer care.
Now, for the first time, profession-wide standards for patient records have been developed in a project co-ordinated by the Royal College of Physicians in partnership with NHS Connecting for Health and agreed by the Academy of Medical Royal Colleges.
The standards, officially launched yesterday, are intended to improve safety by standardising the information held on patients throughout their stay in hospital, reducing the likelihood of mistakes and missing information at admission, handover and discharge.
When it comes to electronic patient records, the main challenge now is to work closely with suppliers on the technical requirements which will bring these standards to bear on them.
More here:
http://www.e-health-insider.com/comment_and_analysis/355/getting_records_up_to_standard
The details are found on the Royal College of Physicians Web Site.
http://www.rcplondon.ac.uk/clinical-standards/hiu/medical-records/Pages/Overview.aspx
The most important documents are found on this page:
http://www.rcplondon.ac.uk/clinical-standards/hiu/medical-records/Pages/clinicians-guides.aspx
Clinicians guides to medical record standards
Based on the work of the Health Informatics Unit, the Digital Information Policy Directorate of the Department of Health and NHS Connecting for Health has published a two part guide for clinicians on the standards for the structure and content of medical records.
Part one provides the background and context of the development of the standards.
Part two provides the standard headings and definitions of the hospital Admission Records, and Handover and Discharge Communications.
There are also other pages with generic guides and templates covering various important processes.
This is clearly sensible and pragmatic work that nicely prepares the way for information which is presently un-standardised and held on paper to be migrated to the world of the EHR.
At first glance they seem to strike a reasonable balance between depth and clinical utility – something I have to say some similar efforts from NEHTA in Australia over the last few years did not achieve. (It is clear, and obvious, that these standards were developed by clinicians and agreed with them – rather than by ivory tower academics as seemed to be the case in much of NEHTA’s work).
These standards should be closely reviewed by Australian Health IT planners and all interested clinicians.
David.
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